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Impact of Individual, Familial and Parental Factors on Adolescent Smoking in Turkey

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Impact of Individual, Familial and Parental Factors on Adolescent Smoking in Turkey International Journal of Environmental Research and Public Health Article Impact of Individual, Familial and Parental Factors on Adolescent Smoking in Turkey Coskun Oztekin 1,†, Mehak Batra 2,†, Shady Abdelsalam 2 , Tijen Sengezer 3, Adem Ozkara 3 and Bircan Erbas 2,4,* 1 Department of Family Medicine, School of Medicine, Hitit University, Corum 19000, Turkey; [email protected] 2 Department of Public Health, School of Psychology and Public Health, La Trobe University, Melbourne 3083, Australia; [email protected] (M.B.); [email protected] (S.A.) 3 Department of Family Medicine, Ankara Numune Research and Training Hospital, Ankara 06000, Turkey; [email protected] (T.S.); [email protected] (A.O.) 4 Faculty of Public Health, Universitas AirLangga, Surabaya 60132, Indonesia * Correspondence: [email protected]; Tel.: +61-394795657 † Equal first author. Abstract: The burden of adolescent cigarette smoking is substantial. We assess mothers’ and fathers’ attitudes and behaviours on adolescent smoking using a cross-sectional study of n = 707 adolescents. Associations between parental attitudes and behaviours in adolescent smoking were assessed using logistic regression separately for boys and girls. Occasional alcohol use by both parents increased odds of smoking once a day (OR = 2.44, 95% CI 1.26, 4.71, OR = 1.51, 95% CI 0.97, 2.35, respectively). Fathers smoking increased odds for girls (OR = 1.59, 95% CI 1.01, 2.52). A democratic mother decreased odds for boys (OR = 0.32, 95% CI 0.10, 0.93) whereas a protective, demanding mother Citation: Oztekin, C.; Batra, M.; increased the odds for girls (OR = 8.65, 95% CI 1.38, 54.22). Public health smoking prevention Abdelsalam, S.; Sengezer, T.; Ozkara, programs could support changing parental behaviours and attitudes in early years to address this A.; Erbas, B. Impact of Individual, burden in countries with authoritarian parenting styles. Familial and Parental Factors on Adolescent Smoking in Turkey. Int. J. Keywords: adolescent; risk; smoking; parental attitudes; parental behaviours Environ. Res. Public Health 2021, 18, 3740. https://doi.org/10.3390/ ijerph18073740 Academic Editor: Sven Bremberg 1. Introduction Cigarette smoking kills almost 8 million people each year and remains the number Received: 11 March 2021 one preventable cause of death [1]. From 2000–2017, globally, around 24.1 million children Accepted: 30 March 2021 aged 13–14 years (about 7%) smoked cigarettes and they still continue to do so. Many Published: 2 April 2021 factors such as biological, psychosocial, and environmental contribute to these behaviours. For example, poor performance in studies, anxiousness, habitual consumption of alcohol, Publisher’s Note: MDPI stays neutral smoking behaviours of parents, siblings, and especially friends, play a role as risk factors [2] with regard to jurisdictional claims in in raising the possibility of starting smoking and the increased likelihood of continuing. published maps and institutional affil- The home environment does seem important, though. Parental non-smoking, and family iations. monitoring and bond [3] seem to be protective, which may contribute to lowering the likelihood of smoking initiation, as well as reducing the likelihood of continuing smoking. The synergistic relationships between the risk and protective factors contribute to the individual’s overall risk profile. To intervene with smoking behaviour, it is imperative to Copyright: © 2021 by the authors. understand the role these factors play to develop early interventions accordingly. Licensee MDPI, Basel, Switzerland. Most European countries have reached great milestones in terms of curbing the tobacco This article is an open access article epidemic. However, challenges are still present. Compared to many other countries, distributed under the terms and tobacco usage remains high in countries like Turkey. Although prohibition has been conditions of the Creative Commons implemented for smoking advertisements, promotion, and sponsorship, populations with Attribution (CC BY) license (https:// varying demographics continue to smoke. Moreover, a substantial number remain exposed creativecommons.org/licenses/by/ to tobacco smoke at home or in private cars as the Tobacco Control Law does not cover 4.0/). Int. J. Environ. Res. Public Health 2021, 18, 3740. https://doi.org/10.3390/ijerph18073740 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2021, 18, 3740 2 of 12 private premises [4]. Countries like Turkey with 30% of its total population being under 15 years of age are faced with a continual burden of smoking uptake at young ages [5]. Resistance among adolescents to interventions that prevent them from smoking is also a further challenge which is a common phenomenon irrespective of country of origin. Studies [6,7] have assessed parenting behaviours on smoking in adolescents as one way to better understand early uptake of childhood risk-taking behaviours. However, these studies are lacking in countries such as Turkey where smoking in younger populations is prevalent [8,9]. Studies have either examined the parenting styles of the mother or father alone but not in combination and they haven’t included smoking and alcohol behaviours of the parents when assessing these effects. Further, across all regions except the Eastern Mediterranean region, the rates of smoking among boys are consistently about 9–10%. For girls, the prevalence seems to be higher in high-income countries whereas for boys the higher prevalence rate is in the upper-middle-income countries such as Turkey [10]. Quitting is always difficult and least common in adolescents. Girls are often faced with many barriers to smoking cessation and are at increased risk of smoking-related mortality and morbidity [11]. Their peers and their standing amongst them both impact their uptake and continuation of smoking [12]. Compared to their male counterparts, younger girls take up smoking as it is deeply related to the vigour of self-concept, i.e., how they identify their appearance and physicality in relation to others [13]. Parental attitudes and behaviours may be important but their role in smoking may be different for boys and girls. Utilising a large cross-sectional study conducted in the Ankara province of Turkey [14], the impacts of individual, familial, and parental factors on smoking outcomes among ado- lescents were assessed. In particular, we sought to examine the effects of parental smoking, alcohol consumption, and individual parenting behaviours. Whether the contribution of these factors differed between boys and girls was also examined. 2. Materials and Methods 2.1. Study Design and Population This analysis is an extension of the cross-sectional study conducted in the Ankara province of Turkey in 2011 on n = 707 students (311 boys and 396 girls) and with an average age of 15.0 years. Depending on the prevalence obtained in the pilot study (45%), 95% confidence level, and 5% allowable error, the minimum sample size required was n = 414.Therefore, the study was sufficiently powered to detect meaningful differences. The participants were recruited randomly from schools in the Akyurt, Bala, and Çankaya districts using simple random sampling [14]. The study collected information on parental, student, and family demographics using a previously validated questionnaire. This study was approved by the Ankara Numune Research and Education Hospital Ethical Committee (Approval Number 2011-253) and the Governor’s Office of Ankara. All students and families provided written informed consent. 2.2. Smoking Consumption Outcome Variables The Addictive Substances Attitudes Scale (ASAS) questionnaire was used to collect information on students’ smoking behaviour variables and attitudes towards smoking as well as alcohol. The questions included and used for the present study were “Have experienced smoking at least once until today”, “Was regularly smoking at least one cigarette daily”, and “The age of starting smoking” for students. Smoking tried at least once and regular smoking were coded as a dichotomous variable based on the responses to the first two questions. “The age of starting smoking” responses were based on multiple choice options <9 years, 10 years, 11 years, 12 years, 13 years, 14 years, and >15 years. For this outcome variable, the logistic regression was coded as <=12 years as an increase in risk. Int. J. Environ. Res. Public Health 2021, 18, 3740 3 of 12 2.3. Parental Behaviours Variables The validated Parental Attitudes Scale (PAS) was used to assess the parental atti- tudes which were classified as democratic, protective/demanding, and authoritative. The responses were measured on a continuous scale. 2.4. Statistical Methods Age was coded ≤15 years or >15 years to be consistent with other studies. Pairwise correlations were assessed between the parental attitudes. Parental attitudes variables were further categorised into quartiles. For the outcome variable “The age of starting smoking”, the categories were merged into ≤12 years and >12 years [15]. Based on the categorical nature of the outcome variables, a logistic regression was considered appropri- ate. A logistic regression model establishes a relationship between an outcome/dependent variable (binary) and a group of predictor/independent variables. These regression models use the logit-transformed probability to enable interpretation as a linear relationship to the independent variables. Here, for example, the binary outcome variable for “Have
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